Shirah Vollmer MD

The Musings of Dr. Vollmer

Psychotherapy: Technique vs. Relationship?

Posted by Dr. Vollmer on April 23, 2015

The longstanding debate in the psychotherapy world centers around the issue that we, the providers, do not understand how we heal. At first pass, it might seem that this field is so uncertain, why would a person devote his/her life to work in which outcomes are vague, and mechanisms of therapeutic action are subject to deep speculation? As with all issues involving uncertainty, the management of “not knowing” involves “pretend knowing” meaning certainty when there is none, and/or embracing the opaqueness of what we do. These two camps, those who feel certain, without science to back them up, and those who coexist with the uncertainty, are antagonistic to one another. I tilt towards embracing complexity and “not knowing” and I begin to tremble at the sound of pseudoscience presenting as science. Having said that, it has felt intuitive to me that people get better through relationships, be that marriages, friendships and/or psychotherapy. Feeling understood and cared about provides the soil in which growth can take place. Yet, one can challenge me and ask that if the most important aspect of psychotherapy is the relationship, than why do I teach “technique” in that most relationships evolve over time without structure or rules. Technique, by my way of thinking, is a litany of structure and rules which is woven together with a therapeutic relationship, resulting in a thoughtfulness about applying or not applying the rules. In other words, there needs to be guidelines in psychotherapy which stimulate the therapist to decide if and when to deviate from those suggestions. Issues such as self-disclosure, doing a home visit, working from home, are all issues which question orthodox views of psychotherapy, and yet with thoughtfulness these rules can be broken with great therapeutic success. The rules promote thinking about thinking and in so doing, therapists need to be taught about how to think about the patient and him/herself at the same time. Two minds engage together, a relationship forms, but the patient is focused on his/her mind, while the therapist is focused on both minds. The asymmetry follows from this thinking pattern, and with this asymmetry the patient learns to trust his/her therapist as someone who is mindful to take care of himself (the therapist) and the patient. This trust that the therapist will neither be a martyr or self-centered allows the patient to explore his/her mind. The relationship, the feeling of mutual caring, with these assigned roles, gives way to introspection and mastery over unconscious motivations. The work is hard because generally speaking, the relationship is necessary but not sufficient for growth. For growth, learning technique is essential. And still, at the end of the day, there is a lot we do not know.

6 Responses to “Psychotherapy: Technique vs. Relationship?”

  1. Ashana M said

    This is a thought-provoking question. Of course, it’s a blend of technique and relationship that’s going on in psychotherapy, but what of each is really essential for healing? I wonder about that because I was in psychotherapy for a long time and really didn’t get a lot better, and now I am not in therapy, and it seems to me–judging just from my own experience of living and functioning–I am getting quite a lot better. As I go through the process, I try to think carefully about what I am doing that is working. What am I doing now that is working that I wasn’t working?

    It seems to me that it’s almost entirely about technique. You need relationships to be human in any way, and they are necessary for healing, but they need not be specifically therapeutic. I think healing from trauma–maybe not other things, but trauma–is about learning. You need specific skills and you need to do something with the trauma material that is, in fact, learning. You can learn on your own or you can learn from a teacher, but it is learning that needs to go on. And, of course, it is usually easier to learn from a teacher provided it’s a good teacher. Learning from someone is necessarily a relationship. Of course, the caring is important. It’s always important in human relationships. The main factor, though, is whether that teacher understands what you need to learn and how your particular mind might best learn it.

    At the same time, when I talk about it as a relationship based on teaching and learning, it’s important to understand that I am not assuming teaching is a didactic process. It is not a matter of sitting down in a room where someone can then instruct you in what to do. That is not really teaching. There may sometimes be a need to present information in a didactic way, but that is fundamentally not how people learn best.

    It’s also important to understand that I don’t mean the patient needs to learn particular ideas. They don’t need to learn they are worthwhile, for example, or that they are safe. They don’t need to be taught particular truisms of that kind. Those might come out of the process, but they aren’t the point and they aren’t the difficult part. What they need to learn are particular emotional and mental skills–not behaviours, but emotional and mental processes which might be supported by a number of actual behaviours–which relate to managing intense emotions. They aren’t complex, but they are difficult I don’t think there are many of them. I think there may only be 3 or 4 at most.

    I think this happens sometimes in the course of therapy, without anyone being aware of what those skills are, but I think if we approached the therapeutic relationship with those skills as objectives from the beginning, we could probably shave years off the timeline.

    • Thanks, Ashana. I appreciate your perspective. The challenge is that what was helpful in your experience may or may not generalize to other patients, so we remain uncertain with each patient about the best way to proceed.

      • Ashana M said

        I am quite certain it would be helpful for other people with trauma histories. I am not unique, and the mental processes involved are the same. The behaviours are going to look different, but the mental process is the same.

      • Ashana M said

        It is attentional control and regulating emotions. Those are the two skills that make healing from trauma possible.

  2. Shelly said

    I appreciated this piece as it gave me insight into what goes on in the doctor-patient relationship. You write, “The relationship, the feeling of mutual caring, with these assigned roles, gives way to introspection and mastery over unconscious motivations.” The thing is, how can there be a feeling of mutual caring when the relationship isn’t mutual?

    • Ah…how can there be mutual caring when the relationship isn’t mutual? The caring is also asymmetrical, but still mutual. In other words both the psychiatrist and the patient care about one another, but through the verbal contract of psychotherapy, there is an agreement that the agenda is to explore the patient’s mind. This does not mean that the patient does not care about the doctor, but only that the time is spent focusing on the mind of the patient. Two people who spend a lot of time together, regardless of the task, often develop a caring and an intimacy which is meaningful. A grandmother who cares for her grandchild engages in a mutually caring relationship, and yet the relationship is in no way mutual.

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